Provider Demographics
NPI:1356436315
Name:KEGEL, WALLY W (DDS, MSD, PS)
Entity type:Individual
Prefix:DR
First Name:WALLY
Middle Name:W
Last Name:KEGEL
Suffix:
Gender:M
Credentials:DDS, MSD, PS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:509 OLIVE WAY
Mailing Address - Street 2:SUITE 627
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-1761
Mailing Address - Country:US
Mailing Address - Phone:206-682-9269
Mailing Address - Fax:206-624-4140
Practice Address - Street 1:509 OLIVE WAY
Practice Address - Street 2:SUITE 627
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-1761
Practice Address - Country:US
Practice Address - Phone:206-682-9269
Practice Address - Fax:206-624-4140
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE000048731223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0300XDental ProvidersDentistPeriodontics